Are Morphometric Alterations of the Deep Neck Muscles Related to Primary Headache Disorders? A Systematic Review

This systematic review aims to summarise the evidence from studies that examined morphometric alterations of the deep neck muscles using diagnostic imaging (ultrasound imaging, magnetic resonance imaging, and computed tomography) in patients diagnosed with primary headache disorders (PHD). No previous reviews have focused on documenting morphometric changes in this population. We searched five databases (up to 12 November 2022) to identify the studies. The risk of bias (RoB) was assessed using the Quality in Prognostic Studies (QUIPS) tool and the overall quality of the evidence was assessed using The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. A total of 1246 studies were screened and five were finally included; most were at high RoB, and the overall level of confidence in results was very low. Only two studies showed a significant association between morphometric alterations of the deep neck muscles and PHD (p < 0.001); nevertheless, their RoB was high. Contradictory and mixed results were obtained. The overall evidence did not show a clear association between morphometric alterations of the deep neck muscles in patients diagnosed with PHD. However, due to the limited number of studies and low confidence in the evidence, it is necessary to carry out more studies, with higher methodological quality to better answer our question.


Introduction
Headache has been defined as localized pain in the head above the orbitomeatal line and/or the nuchal crest. The main tool used to make the diagnosis of headache disorders is The International Classification of Headache Disorders (ICHD). Its last edition, ICHD-3, classifies primary headaches (PH) as follows: migraine, tension-type headache (TTH), trigeminal autonomic cephalalgias (TACs), and other primary headache disorders (PHD) [1]. PH are disorders by themselves, and they are caused by independent pathomechanisms and not by other disorders [1].
Headaches are one of the most common and disabling dysfunctions of the nervous system. About 95% of the world's population has experienced some type of headache at least once in their lives [2]. The impact of headaches on the population is very high [2]. In Europe [3], headaches have been found to affect 15% of the population [3]. The prevalence

Inclusion and Exclusion Criteria
Inclusion criteria: (i) Population: studies with patients of any age or sex with a PHD diagnosis made by a health professional using the ICHD classification; (ii) Intervention/exposure/factor: any study that employed diagnostic imaging methods (US, magnetic resonance imaging (MRI), computed tomography (CT)) [32] with their variable of interest being muscle size (measured by muscle cross-sectional area (CSA) or muscle volume quantification (MVQ)); (iii) Comparison: subjects with no headaches; (iv) Outcome: Our main outcome was the development/progression of PH. However, since we anticipated that prospective cohort studies answering our question would be limited or non-existent, we were also interested in determining whether people with PH in comparison with people without these diagnoses have morphometric impairments of the deep neck muscles evidenced by MRI or US assessment. Measures of association (odds ratios, correlation coefficients) between morphometric impairments of the deep neck muscle and PH (development and/or progression of PH) were sought; and (v) Studies: observational studies such as prospective cohort, cross-sectional studies, retrospective cohort studies, and case control studies were targeted since these designs are suitable to answer our question.
Exclusion criteria: (i) Population: studies whose patients had evidence of any secondary headache, who were receiving physical therapy in the cervical region and diagnosed with medication overuse headache; (ii) Intervention/exposure/factor: studies that used clinical examination, physical examination or a non-validated tool; (iii) Comparison: studies with no comparison group; and (iv) Studies: clinical trials, systematic reviews, meta-analyses, reviews, case reports, letters to the editor, conference articles, book chapters, protocol registries, grey literature, cadaver studies and animal studies.

Selection of Studies
All search results were exported to EndNote. All duplicates were removed from EndNote and the results were imported into Covidence (www.covidence.org, accessed on 1 April 2020). The screening process was performed by two independent reviewers based on the inclusion criteria described above and divided into two stages: title/abstract review and full-text review. In cases of disagreement, a third reviewer intervened to discuss and resolve the conflict. The PRISMA 2020 flow chart (Figure 1) was used to organise and keep track of the number of duplicates, selected and eliminated studies.

Data Extraction
Data extraction (DE) was carried out using a structured excel data collection sheet. This sheet included different fields of interest and drop-down menus to extract all the information of interest. To ensure that all reviewers extracted the information in the same way, a pilot process of data extraction was conducted. One reviewer extracted and organised the data in this DE sheet. A second reviewer checked all the extracted data. If discrepancies occurred, a consensus meeting was held. If consensus was not possible, a third reviewer ensured consensus.

Data Extraction
Data extraction (DE) was carried out using a structured excel data collection shee This sheet included different fields of interest and drop-down menus to extract all th information of interest. To ensure that all reviewers extracted the information in the sam way, a pilot process of data extraction was conducted. One reviewer extracted and organ ised the data in this DE sheet. A second reviewer checked all the extracted data. If discrep ancies occurred, a consensus meeting was held. If consensus was not possible, a third re viewer ensured consensus.
The extracted data were based on characteristics including but not limited to articl information (first author's name, year of publication, language, funding, country, mai objective, study design and setting), population information (e.g., age, gender, ethnicity diagnosis, diagnostic tool, other conditions or characteristics), exposure characteristic (e.g., imaging method used, muscles of interest, validated method), outcomes (type o outcome, tool used, units, meaning of values), summary of results, data analysis, conclu sions, limitations/comments, and recommendations. In the case of any missing data o interest, the authors were contacted to obtain the unreported data.

Risk of Bias (RoB)
The RoB assessment of the included studies was performed concurrently with dat The extracted data were based on characteristics including but not limited to article information (first author's name, year of publication, language, funding, country, main objective, study design and setting), population information (e.g., age, gender, ethnicity, diagnosis, diagnostic tool, other conditions or characteristics), exposure characteristics (e.g., imaging method used, muscles of interest, validated method), outcomes (type of outcome, tool used, units, meaning of values), summary of results, data analysis, conclusions, limitations/comments, and recommendations. In the case of any missing data of interest, the authors were contacted to obtain the unreported data.

Risk of Bias (RoB)
The RoB assessment of the included studies was performed concurrently with data extraction. This stage was performed by two independent reviewers using The Quality in Prognostic Studies (QUIPS) tool for assessing risk of bias of observational studies. This tool provides six risk of bias domains: (1) study participation, (2) study dropout, (3) measurement of prognostic factors, (4) measurement of outcomes, (5) study confounders, and (6) statistical analysis and reporting. Each of the six domains of potential bias can be rated as high, moderate, or low risk of bias. For the overall quality of the study, we developed decision rules as stated in previous research (Hayden et al. 2019) [33].

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High risk of bias: If the study was rated high in at least one domain. • Moderate risk of bias: If the study was rated moderate in at least one domain, and the other domains were low. • Low risk of bias: If the study was rated as low in all six domains.
If consensus could not be reached, an independent third opinion was sought to help resolve any differences.

Data Synthesis
A narrative (descriptive) synthesis of the results is presented. Evidence tables have been used to compare study details, summarise results, and perform analyses. Data synthesis has been performed according to the type of imaging method used (e.g., US, MRI), the PH diagnosis (e.g., migraine, TTH, TACs, other), and according to the type of outcome (CSA, MVQ).
The results were also summarised according to the risk of bias. A meta-analysis was not carried out due to the great heterogeneity of the headaches analysed, the comparators, the musculature of interest and the outcomes (area/volume measurements). Therefore, we were only able to perform a qualitative narrative synthesis of the results of interest as presented in tables and summarised in figures. We present standardized mean differences (SMD) as measures of effect sizes (ES) of the variables of interest from individual studies to facilitate comparison between studies, as suggested by the Cochrane collaboration.
The quality of the body of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We used the guidelines provided by Huguet et al. [34] adapted to observational studies. Review Manager (RevMan 5.4.1, The Cochrane Collaboration) software was used to display figures with the distribution of the data obtained. The evidence was classified as high (++++), moderate (+++), low (++) and very low (+), as described by Huguet et al. [34]. For each domain or risk factor, the following was analysed: (1) phase of the research; (2) limitations of the study (3) inconsistency of the results, (4) indirectness (not generalizable), (5) imprecision (insufficient data) and (6) publication bias. The (7) effect size and (8) dose effect were not evaluated as a meta-analysis could not be performed. However, trends in the data were inspected, when possible.
Subgroups analyses were performed when feasible based on the imaging tool and outcome variable obtained to determine the study quality and risk of bias of the included studies.

Selection of Studies
After the electronic search in the five databases, a total of 2299 studies were found, as summarised in the PRISMA flowchart ( Figure 1). EndNote and Covidence identified 1053 duplicates and these were removed before screening. A total of 1246 articles were screened and after the first screening of titles/abstract, n = 1227 studies were eliminated. A total of 19 studies were read in full text. The reasons for exclusion are available in Table A3 and outlined in the PRISMA flowchart ( Figure 1). Five studies remained and were selected and analysed for this review: Fernández de las Peñas et al. [35], Hvedstrup et al. [23], Wanderley et al. [36], Oksanen et al. [37] and Xiao Ying-Yuan et al. [25].
A summary of the general characteristics of the five studies included in this review is shown in Tables 1 and A4. The studies included in this systematic review were published between 2007 and 2020 and all were observational cross-sectional studies.
The five studies included a total sample of 458 participants. The mean ages of the patients varied from 17 years [37] to 43.5 years [25].
Two of the studies only considered women [35,36], and in the remaining three studies, the sex was mixed (in total, 318 women and 140 men were included).

Primary Headaches Disorders
The studies included different diagnoses of PH. Two studies focused on a single type of PH: TTH [23,35], and migraine [23]. Two studies included both TTH and migraine [36,37]. In the remaining article [25], although the author was contacted by email, we could only confirm that they studied PH and that they used the ICHD criteria for their diagnosis; however, the specific diagnosis was not provided.
All the studies used the criteria of the International Headache Society (IHS) as a diagnostic tool. The classification used in four of them was the 2nd edition of ICHD. In the study by Oksanen et al. [37], the IHS criteria (1988) were used as the diagnosis of the patients was made before the publication of the ICHD-2. Information on headache frequency and years lived with headaches is provided in Table 1.

Diagnostic Imaging
Two imaging methods were used in the selected studies: MRI and US. Four studies used MRI [23,25,35,37] and only one [36] used US. The radiological interpretation was blinded in four of the studies, but we do not have this information for the article by Yuan et al. [25].

Outcomes of Interest
Two different outcomes were used in the selected studies: CSA and MVQ. Four articles used CSA as an outcome [25,36,37].
A meta-analysis was not possible due to the great heterogeneity of the headaches analysed, the comparators, the musculature of interest and the outcome variables (area/volume measurements). Therefore, we only were able to perform a qualitative analysis and a narrative synthesis of the outcomes, which are presented in Figures 2-4.

Diagnostic Imaging
Two imaging methods were used in the selected studies: MRI and US. Four studies used MRI [23,25,35,37] and only one [36] used US. The radiological interpretation was blinded in four of the studies, but we do not have this information for the article by Yuan et al. [25].

Muscles Tested
The muscle most frequently examined in the included studies was the RCPmi, as three of the studies [23,25,35] analysed its morphometric alterations. Only one study [36] examined the longus colli (LC), and the rectus capitis posterior major (RCPma) was also examined by one study [35]. Finally one study analysed the rotators, multifidus colli and semispinalis colli [37]. This last study [37] grouped the morphometric measures of the three muscles into a single area. Both Fernández de las Peñas et al. [35] and Oksanen et al. [37] examined the size of the superficial cervical musculature as well. They analysed the semispinalis capitis, splenius capitis [35,37], sternocleidomastoid, scalenus, splenius colli, levator scapulae and trapezius [37].

Outcomes of Interest
Two different outcomes were used in the selected studies: CSA and MVQ. Four articles used CSA as an outcome [25,36,37].
A meta-analysis was not possible due to the great heterogeneity of the headaches analysed, the comparators, the musculature of interest and the outcome variables (area/volume measurements). Therefore, we only were able to perform a qualitative analysis and a narrative synthesis of the outcomes, which are presented in    [37], and Xiao-Ying et al. [25].

Morphometric Alterations
This section is divided according to the analysis presented by the studies and as reflected in the forest plots (Figures 2-4).
• TTH vs. control (CSA, MRI) ( Figure 2): Two studies [35,37] investigated TTH and analysed the CSA of the RCPmi, RCPma, rotators, multifidus, and semispinalis cervicis compared with an asymptomatic control group. As shown in the forest plot ( Figure  2), the study by Oksanen et al. [37] did not observe statistically significant differences in any of the variables when comparing TTH and the control subjects. This study assessed the CSA in rotator, multifidus, and semispinalis cervicis, both in females in the right side. The SMD ranged from 0.16 to −0.41. In contrast, Fernández de las Peñas et al. [35] observed statistically significant differences between groups. The magnitude of effects (SMD) in the different comparisons was greater. The SMDs ranged from −0.89 to −1.46. These differences were considered clinically relevant [35]. Changes were noted, but they were not of a sufficient magnitude to be considered relevant. The CSA in the extensor muscles was greater (p < 00.1) in men than in women [37].

Morphometric Alterations
This section is divided according to the analysis presented by the studies and as reflected in the forest plots (Figures 2-4).
• TTH vs. control (CSA, MRI) ( Figure 2): Two studies [35,37] investigated TTH and analysed the CSA of the RCPmi, RCPma, rotators, multifidus, and semispinalis cervicis compared with an asymptomatic control group. As shown in the forest plot ( Figure 2), the study by Oksanen et al. [37] did not observe statistically significant differences in any of the variables when comparing TTH and the control subjects. This study assessed the CSA in rotator, multifidus, and semispinalis cervicis, both in females in the right side. The SMD ranged from 0.16 to −0.41. In contrast, Fernández de las Peñas et al. [35] observed statistically significant differences between groups. The magnitude of effects (SMD) in the different comparisons was greater. The SMDs ranged from −0.89 to −1.46. These differences were considered clinically relevant [35]. • Migraine vs. control (CSA, MRI) ( Figure 2): Only one [37] of the five included studies evaluated the CSA of the rotator, multifidus and semispinalis cervicis, comparing subjects with migraine and asymptomatic subjects. The results, displayed in the forest plot ( Figure 2), show changes in the different groups of interest. The area of the three named muscles was assessed with a unique measure separated by sexes. The values were grouped for males and females. The SMDs ranged from 0.69 to −0.45. Changes were noted, but they were not of a sufficient magnitude to be considered relevant. The CSA in the extensor muscles was greater (p < 00.1) in men than in women [37]. • Primary headache (general) vs. control (CSA, MRI) ( Figure 2): Only the study by Yuan et al. [25] evaluated the CSA as a variable in a primary (general) headache group in the RCPmi of the head compared with an asymptomatic group. Looking at the analysis of the different comparison groups in the study by Yuan et al. [25] (headache vs. control), in general, considering women and men together, a SMD [95% CI] = 1.27 [0.99, 1.56] was obtained, which is considered a large effect. In addition, differences between groups were observed when women and men were analysed separately. In this comparison group, it was also observed that the RCPmi had a larger area in men than in women (p < 0.001).   Figure 4). However, this study showed a statistically significant (p < 0.001) higher volume in the male group than in the female group.

Risk of Bias (QUIPS)
As previously mentioned, the risk of bias of each study was assessed by a set of domains of the QUIPS tool. Each domain analysed is summarised in Table 2. Four studies (80%) were assessed as having a high overall risk of bias, and the remaining article (20%) was considered to have a moderate risk of bias. Most studies (80%) had a moderate risk assessment in the outcome measurement domain, and 80% also had a high-risk of bias in the confounding domain. All of the studies (100%) were judged to be at low risk of bias in the study dropout domain ( Figure 5). As all studies were of cross-sectional design, it was anticipated that attrition biases were not an issue. In addition, differences between groups were observed when women and men were analysed separately. In this comparison group, it was also observed that the RCPmi had a larger area in men than in women (p < 0.001).  Figure 4). However, this study showed a statistically significant (p < 0.001) higher volume in the male group than in the female group.

Risk of Bias (QUIPS)
As previously mentioned, the risk of bias of each study was assessed by a set of domains of the QUIPS tool. Each domain analysed is summarised in Table 2. Four studies (80%) were assessed as having a high overall risk of bias, and the remaining article (20%) was considered to have a moderate risk of bias. Most studies (80%) had a moderate risk assessment in the outcome measurement domain, and 80% also had a high-risk of bias in the confounding domain. All of the studies (100%) were judged to be at low risk of bias in the study dropout domain ( Figure 5). As all studies were of cross-sectional design, it was anticipated that attrition biases were not an issue.

Quality of Studies (GRADE)
The certainty of the studies was assessed using the GRADE [33,34] system, as shown in Table 3. The adaptation of Huguet et al. [34] for articles assessing prognostic factors was used. The overall quality of evidence in the studies was very low in the different comparisons due to heterogeneity, high risk of bias and imprecision. The inconsistency parameter was not assessed in all cases since, if the comparison only included one study, this section was considered as "not applicable". Publication bias was not an element that devalued quality in this systematic review since the search for all included studies was performed carefully, as shown in Table 3. The study(s) are rated in QUIPS with a high risk of bias. b . There is heterogeneity among the studies since the direction of the results obtained varies among them. c . Although the outcome variable, the diagnostic method and the prognostic factor are adapted to our hypothesis, the sample is not representative of the population and the type of study does not answer the original question because it is cross-sectional. d . Since the sample size is less than 300 subjects, we consider the imprecision to be serious. e . The study is rated in QUIPS with moderate risk of bias. f . No quantitative data were pooled. The study is QUIPS rated with moderate risk of bias. Quantitative data were not pooled as the analysis of the studies was performed from a qualitative point of view.

Main Results
This systematic review shows controversial findings regarding whether morphometric alterations of the deep neck muscles are present in subjects with PH. There was not a clear pattern or direction of results. It is uncertain whether the size of the deep neck muscles is reduced or not in individuals with PH based on the included studies. We can say that patients with PH may present morphometric alterations of the deep cervical musculature. However, the direction of this alteration is not clear.
For example, Fernández de las Peñas et al. [35] obtained statistically significant results and a large effect, showing that RCPmi and RCPma have a smaller CSA compared with the control group. Therefore, this study reported the presence of atrophy of these muscles in patients with PH, specifically chronic TTH. It should be noted that the RoB in this study is high, and the sample size is small. In contrast, the study by Yuan et al. [25], which also obtained statistically significant results and a large effect, concluded that the RCPmi has a larger CSA, and thus, that there is hypertrophy of these muscles in patients with primary (chronic) headaches. This study was also evaluated at a high RoB. Although morphometric changes of the cervical musculature were observed in both studies, it was not possible to determine whether this factor was a primary or secondary phenomenon to the PH due to the simplistic analyses conducted in these studies.
The study by Oksanen et al. [37] shows lower CSA of the rotators, multifidus cervicis, and semispinalis cervicis in subjects with PH. However, the study carried out by Hvedstrup et al. [23], in agreement with Yuan et al. [25], observed greater volumes of the RCPmi (without being statistically significant, and presenting a small effect size), which contradicts the results found by Oksanen et al. [37]. The mean age of the sample in this study by Hvedstrup et al. [23] was 17 years, comparatively lower than in the rest of the studies, which may affect both the chronicity of the headache and the years of evolution. The heterogeneity of the studies could explain in part the differences in their results.
The literature has highlighted the crucial role that the deep neck muscles play in the cervical spine due to its stabilisation function [38]. In particular, the suboccipital musculature is characterised by a high concentration of muscle spindles, up to five times more than the splenius capitis or three times more than the semispinalis capitis [39]. In addition, these muscles which have a high concentration of muscle spindles play an important role in correct motor control of the neck [40]. Therefore, it is expected that these muscles could be affected in subjects with head-and neck-related disorders. However, based on recent evidence, there is no direct relationship between cervical motor control (in this case, of the suboccipital muscles) and PH [41]. This aligns with the results of our systematic review, where a direct relationship between morphometric alterations of the deep neck muscles and PH was also not observed.

Previous Studies and Systematic Reviews
We could say that the hypothesis raised in our study is an emerging question since, as described above, we have not found previous systematic reviews analysing the same topic of interest. The systematic review published in 2019 by Liang et al. [9] focuses on functional, rather than structural, alterations of the cervical musculature in patients with migraine and TTH. Although the review by Liang et al. [9] did not determine a direct relationship between both variables, greater functional alterations, such as greater forward head posture or less cervical range of motion were identified in patients with TTH when compared with subjects with migraine. Other systematic reviews, such as the one published by Ignacio Elizagaray et al. [41], have focused on forward head posture in patients with PHD. This publication [41], consistent with Liang et al. [9], concludes that there may be a greater FHP in patients with chronic PH in comparison with those with episodic PH or healthy controls.
Previous research has been interested in morphometric alterations of different muscles related to PH. For example, the publication by Pereira de Castro Lopes et al. [42] reported that patients with migraine (and associated signs and symptoms in the temporomandibular joint) presented hypertrophy of the lateral pterygoid muscle.
On the other hand, US has been used to determine muscle thickness in the obliquus capitis inferior (OCI) [27], LC [26] and longus capitis, obliquus capitis superior (OCS) and RCPma muscles [28], and in most cases, determined a lower muscle thickness in patients than in healthy subjects. In all three studies, however, US was used in patients with CEH, which is not applicable to our research.
However, as mentioned before, none of the previous reviews have focused on documenting morphometric changes in this population. Thus, our review provides novel evidence regarding this literature.

Heterogeneity of Parameters
As we have already explained, several factors contributed to the great heterogeneity found in the included studies. For example, the selected studies had different characteristics in relation to types of PH, sexes, methods of morphometric measures, methods of diagnostic imaging used, MRI equipment, patient positioning, cervical spine levels for taking measurements, and software used, among other factors. This great variability in the studies prevented us summarising the evidence efficiently or performing a meta-analysis. In addition, we were unable to explore sources of heterogeneity with subgroup analyses (e.g., based on the RoB, types of headaches, outcomes) or meta-regression since the number of studies was limited.

Risk of Bias/Certainty of the Evidence
We undertook a careful RoB assessment process, and several key elements from the analysed studies reduced our confidence in the results. First, the RoB due to potential confounders was high in many of the studies. Several publications did not control for confounding variables such as height, weight, body mass index, physical activity, cervical spine symptoms (pain, cervical disability index, myofascial trigger points), headache frequency or years lived with headache. In other cases, despite collecting data on some of the variables, they were not included in the statistical analyses. Regarding the quality of evidence, the confidence level of these studies was low due to the heterogeneity of the comparisons, the small sample sizes, as well as the methodological approaches of the studies.
One of the main limitations of the results obtained in this systematic review was the type of study designs used in the included studies. All the publications included in this review were cross-sectional studies. This made it impossible to follow up the participants to establish an association between the alterations in the deep cervical muscles and the onset of headache. Therefore, it is not possible to conclude a causal association between cervical alterations and the development of headache.
As suggested by other publications, there could be an overlap between the symptoms of chronic migraine and CEH [43], and thus, patients with chronic migraine are commonly diagnosed as having CEH. This could affect the accuracy of the diagnoses used in the included studies [44].
Age also has been considered a factor which is related to muscle mass. Starting in middle-aged adults, there is a loss of muscle mass, and thus, studies should be limited to a more specific age range [45] or consider age as a covariate in their statistical analyses. In addition, physical activity has been reported to influence muscle mass [46,47], and thus, analyses of studies should also take this factor into account.

Limitations and Strengths of This Review
We followed strict standards and up-to-date methods to conduct this systematic review. Comprehensive search strategies as well as manual search and tracking of references were conducted to identify potential studies for inclusion. The newly developed PRISMA guidelines were used to report the results. Furthermore, all the authors were well trained to perform data extraction and quality assessment in a reliable and consistent manner. In addition, the full text of the selected articles was read by two independent reviewers to avoid selection biases.
Due to the insufficient number of studies in the comparisons, publication bias was not assessed in this systematic review. In any case, the search strategy was performed in an exhaustive and expert-supervised manner to avoid publication biases.
In addition, all the included studies based their findings on very small sample sizes, and it is possible that these results are not applicable to the whole population since their variability was very high.

Implications for Clinical Practice and Research
Due to the limited evidence (low number of studies) and their high RoB as well as their inconsistent results, we can say that there is no clear pattern of morphometric alterations of the deep neck muscles in patients with PH and practical recommendations are uncertain. The results of this systematic review highlight the need for well-planned future studies with better methodological quality and longitudinal design to determine a possible causality of this factor on PH and, therefore, to establish guidelines in the treatment of PH. The need for more research in this area is by itself an important and useful finding for clinical and research practice.
As explained in other sections, previous systematic reviews show the existence of functional alterations in the deep neck muscles in primary headaches [9]. Other studies have also observed these functional changes in cervicogenic headache [48]. In both cases, the evaluation by a physical therapist is recommended. On the other hand, a systematic review conducted in 2022 concluded that craniocervical exercises (involving the deep cervical musculature [49]) improve disability and quality of life in patients with primary headache, especially in patients with TTH [50]. In our systematic review we observed morphometric changes in patients with primary headache in comparison with healthy subjects. Although the evidence from the analysed studies is still limited and firm conclusions cannot be stated, our results point out the need for these muscles to be evaluated by specialized health professionals to determine their role in the symptomatology of individual patients.
We believe that the use of US should be implemented as a method of measuring morphology as it is cost effective, rapid [51] and a more accessible tool for physical therapists and other health professionals for rehabilitation and diagnosis [52]. Previous studies have validated the use of US to measure the CSA of the deep cervical muscles and have found US to be as effective as MRI [53]. The development of US in recent years has allowed better visualisation of the deep neck muscles [53]. We therefore believe that there should be future studies using this diagnostic imaging tool as the method of choice.
Although the evidence from the analyzed studies is still limited and firm conclusions cannot be stated, our results pointed out the need to evaluate these muscles by a specialized health professional, to determine their role in the symptomatology of individual patients.

Conclusions
Based on the included studies, it can be said that there are morphometric alterations of the deep cervical musculature in patients with primary headache compared with individual without primary headaches. However, the magnitude or direction of these alterations are not clear. Due to the variability of results, the heterogeneity of the comparisons, and the design of the studies, we cannot conclude what influence that morphometric alterations of the deep cervical muscles may have on the pathogenesis of primary headaches.
Future studies are needed to increase the body of evidence. These preliminary data show the urgent need for quality research on the direction of morphometric changes of the deep neck muscles in primary headaches to guide decision making.

Conflicts of Interest:
The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. Pubmed (n = 749, Filters: no) (paraspinal muscles or neck muscles or "deep neck muscles" or "deep cervical muscles" or musculi suboccipitales or suboccipital muscles or rectus capitis or "rectus capitis posterior minor" or "rectus capitis posterior major" or "rectus capitis lateralis" or "rectus capitis anterior" or obliquus capitis or obliquus capitis superior or obliquus capitis inferior or multifidus colli or multifidus cervicis or semispinalis or "rectus capitis anterior" or obliquus capitis or obliquus capitis superior or obliquus capitis inferior or multifidus colli or multifidus cervicis or semispinalis colli or "semispinalis cervicis" or longus colli or "longus cervicis" or longus capitis) AND (headache disorders, primary or tension type headache or migraine disorders or "cluster headache" or trigeminal autonomic cephalalgias or headache or "headache disorders" or "sick headache" or "primary headache" or "primary cephalalgias" or "tension headache" or "stress headache" or "histamine cephalalgia" or megrim or migrainous or cephalalgia or migraine or cephalalgy) Medline (Ovid) (n = 415 Filters: no) exp *Neck Muscles/OR neck muscl*.mp. OR exp *Paraspinal Muscles/OR paraspinal muscl*.mp. OR (deep neck muscl* or deep cervical muscl* or musculi suboccipitales or suboccipital muscl* or rectus capitis or rectus capitis posterior major or rectus capitis posterior minor or rectus capitis lateralis or rectus capitis anterior or obliquus capitis or obliquus capitis superior or obliquus capitis inferior or multifidus colli or multifidus cervicis or semispinalis colli or semispinalis cervicis or longus cervicis or longus colli or longus capitis).mp. AND exp *headache disorders, primary/or exp *migraine disorders/or exp *tension-type OR headache/or exp *trigeminal autonomic cephalalgias/OR headache disorders, primary.mp. OR exp *Tension-Type Headache/OR tension-type headache.mp. OR exp *migraine disorders/or exp *alice in wonderland syndrome/or exp *migraine with aura/or exp *migraine without aura/or exp *ophthalmoplegic migraine/migraine.mp. OR exp *trigeminal autonomic cephalalalgias/or exp *cluster headache/or exp *paroxysmal hemicrania/or exp *sunct syndrome/OR cluster headache.mp. OR exp *Headache/OR headache.mp. OR exp *headache disorders/OR exp *headache disorders, primary/OR headache disorders.mp. OR ((sick or primary or tension or stress) adj3 headache).mp. OR (sick headache* or primaryheadache* or primary cephalalgia* or tension headache* or stress headache* or histamine cephalagia* or megrim or migrainous or cephalalgia* or cephalalgy).mp.

CINHAL (n = 242 Filters: academic publications)
The same terms were used as in Medline.
Study results: No significant differences were found between right and left Rcsa. Patients with CTTH showed reduced rCSA in RCPmin and RCPmaj. The greater the headache intensity, duration or frequency, the smaller the Rcsa.